What Is Chauffeur’s Fracture? – Diagnosis, Treatment

What Is Chauffeur’s Fracture? /Chauffeur’s Fracture, also known as Hutchinson fracture, is a type of fracture of the forearm, specifically the radial styloid process. The injury is typically caused by compression of the scaphoid bone of the hand against the styloid process of the distal radius. It can be caused by falling onto an outstretched hand. Treatment is often open reduction and internal fixation, which is a surgical realignment of the bone fragments and fixation with pins, screws, or plates.

Radial styloid fractures can occur in isolation or in association with other injuries, including complex intra-articular distal radius fractures, carpal fractures, carpal dislocations, and radiocarpal dislocations. The anatomy surrounding the radial styloid is complex, and complications related to the surgical approach, treatments, and symptomatic hardware can occur. Operative treatments vary according to the injury pattern present, and pattern recognition is the key to optimizing the treatment of these injuries. Outcomes are related to the precision of the reconstruction as well as the magnitude of the injury; better results are associated with lower-energy patterns.

Causes Of Chauffeur’s Fracture

Chauffeur's Fracture

  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of broken radial styloid fractures.
  • Sports injuries – Many radials styloid fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wrist bones to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms Of Chauffeur’s Fracture

Common symptoms of radial styloid fractures include:

  • Severe pain that might worsen when gripping or squeezing or moving your hand or wrist
  • Swelling
  • Tenderness
  • Bruising
  • Obvious deformity, such as a bent wrist
  • Pain
  • The wrist hanging in a deformed way
  • Pain, especially when flexing the wrist
  • Deformity of the wrist, causing it to look crooked and bent.
  • Your wrist is in great pain.
  • Your wrist, arm, or hand is numb.
  • Your fingers are pale.

Diagnosis of Chauffeur’s Fracture

History

Your doctor in the emergency department may ask the following questions

  • How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
  • When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
  • What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
  • Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
  • What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit,  anabolic steroid uses for athletes, etc?

Physical

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.

  • Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
  • Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture.
  • Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
  • Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side.
  • Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
  • Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

Plain Radiographs

  • Radiographic imaging is important in diagnosis, classification, treatment, and follow-up assessment of these fractures. The routine minimal evaluation for radial styloid fractures must include two views-a posteroanterior (PA) view and a lateral view.[rx]
  • The PA view should be obtained with the humerus abducted 90 degrees from the chest wall, so that the elbow is at the same level as the shoulder and flexed 90 degrees.[rx] The palm is maintained flat against the cassette

Computed Tomography

  • CT may be useful and can give significant information in comparison with that obtained with conventional radiography in the evaluation of complex or occult fractures, radial and ulnar shaft articular surface, distal radio-ulnar joint, ventromedial fracture fragment (as described by Melone),[rx] assessments of fracture healing as well as post-surgical evaluation.[rx]
  • CT may be indicated for the confirmation of occult fractures suspected on the basis of physical examination when plain films are normal.

Magnetic Resonance Imaging

  • Although this modality is not the first choice in evaluating acute distal radius fractures, it is a powerful diagnostic tool to assess bony, ligamentous, and soft tissue abnormalities associated with these fractures.
  • MRI has proved to be a very important diagnostic tool for delineating perforation of triangular fibrocartilage complex (TFCC),[rx] perforation of interosseous ligaments of the proximal carpal row, evaluating occult fractures, post-traumatic or avascular necrosis of carpal bones.

Treatment Of Chauffeur’s Fracture

Non-Surgical

Treatment available can be broadly

  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your shoulder area, then get medical care immediately. Radial styloid process fractures cause significant pain in the front part of your shoulder, closer to the base of your neck. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the arm/hand.
  • Apply ice to your fractured area – After you get home from the hospital radial and styloid process fractures (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your clavicle for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
    Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your arm and shoulder in all different directions. Don’t aggravate the radial and styloid process fractures so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light calisthenics and then progress to holding light weights (five-pound weights to start). Your distal radius fractures need to move a little bit during the later phases of the injury to stimulate complete recovery.
  • Practice stretching and strengthening exercises – of the fingers, elbow, and shoulder if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Get a supportive arm sling – Due to their anatomical position, distal radius fractures can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body. You’ll need to wear the sling constantly until there is no pain with arm movements, which takes between two to four weeks for children or four to eight weeks for adults.
  • Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your shoulder and upper chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and shoulder movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
  • Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with radial and styloid process locking plate, coracoclavicular screws, Knowles pin fixation.
  • Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for styloid process ligament reconstruction.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)

Rest Your Hand

Once you’re discharged from the hospital in an arm sling, your top priority is to rest your shoulder and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
  • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
  • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the radial and ulnar shaft fractures.
  • Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
  • Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the styloid process injury.

Physical Therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  After a radial and ulnar shaft fractures, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-Up Care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

  • To elevate breathing problems or remove lung congestion if needed.

Do no HARM for 72 hours after injury

  • Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
  • Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
  • Running and movement – Running and walking may cause further damage, and causes healing delay.
  • Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

  • Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgical Treatment

Surgical Fixation: fixation of radial styloid begins at the tip, which is best approached via a small incision along the margin of 1st dorsal compartment (APL, EPB); although K wire or cannulated lag screw fixation can be achieved percutaneously, it is advisable to make small incision; remember that the radial styloid lies slightly volar to the mid axis of the radius, and therefore the wire should be directed slightly dorsally as well as clearly and proximally; the reduction is secured w/ either K wire or lag screw;

3 indications formal ORIF; 

Rotational displacement in axial or coronal plane may prove difficult to overcome, or hematomas may interfere w/ reduction; interposed tissue (FCR, or rarely wrist extensors); metaphyseal defect after reduction which requires bone grafting; use of either a small drill guide or tissue protector to protect dorsal sensory radial nerve;

Evaluation of reduction:

the articular reduction is best evaluated by radiocarpal arthrotomy between second & fourth dorsal compartments, just distal to Lister’s tubercle; when bone grafting is necessary, placement is usually required in the area between the first and second dorsal compartments; K wire fixation devices should pass perpendicular to the fracture site, enter the tip of the radial styloid, and exit proximal to distal RU joint; stabilization of styloid w/ K wires alone is hazardous, because medial, single cortex fixation is often insufficient to prevent replacement; as an alternative, two cancellous screws (4.0 mm cancellous) or  3.5 mm cortex screws or 3.5 mm cannulated screws; buttress plate is more reliable (2.7 mm condylar plate)

Rehabilitation Guideline For Non-Operative/Conservative Rehabilitation [Rx]

Acute Stage (0-8 weeks)

Goals

  • Protection with short-arm cast
  • Control pain and edema
  • Maintain range in digits, elbows, shoulder

Interventions

  • AROM and PROM of digits, elbow, shoulder
  • Elevation of hand and digits to control edema
  • Cast removal between 6-8 weeks

Sub Acute Stage

Goal

  • Control pain and edema (TENS, ice)
  • Increase ROM
  • Increase activities of daily living (ADLs)

Interventions

  • AROM and PROM of digits, elbow, shoulder
  • AROM wrist flexion/ extension, forearm supination/ pronation
  • PROM of low load and prolonged stretch

Settled Stage

Goals

  • Regain full ROM
  • Begin strengthening
  • Return to activity

Interventions

  • Continue all ROM exercises
  • Progress to the strengthening of all joints[rx]

Rehabilitation Guideline For External Fixation

Acute Stage (1-6 weeks)

Goals

  • Control pain and edema (TENS, ice)
  • Protect surgical site
  • Maintain ROM of digits, elbow, shoulder

Interventions

  • Elevation
  • AROM of digits, elbow, shoulder
  • AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

Goal

  • Protect fracture site
  • Control pain and edema (TENS, ice)
  • ROM of involved and uninvolved joints

Interventions

  • AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

Goal

  • Regain full ROM
  • Begin strengthening
  • Increase tolerance to ADLs

Interventions

  • ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
  • PROM of low load and prolonged stretching of wrist motions
  • Grip strengthening
  • ADL training within tolerance[rx]

Cryotherapy

  • Cryotherapy is an effective modality for controlling edema in the acute phase after trauma and during rehab due to its ability in helping to decrease blood flow through vasoconstriction limiting the amount of fluid escaping from capillaries to the interstitial fluid[rx]. Cryotherapy can also be combined with compression and elevation in the treatment of edema.[rx]
  • To control pain using cryotherapy, the modality should be applied to the area for 10-15 minutes which can result in pain control up to 2 hours post application.[rx]Precautions for the use of cryotherapy include: over a superficial branch of the nerve, over an open wound, poor sensation or mentation, and very young or very old patients.[rx] Contraindications for cryotherapy include; Acute febrile illness, Vasospasm e.g. Raynaud’s disease, Cryoglobulinemia, Cold urticaria.[rx]

Electrical Stimulation

  • The use of transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct during any phase of rehab to address pain but can be particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.[rx]
  • Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. Low-rate TENS has been reported to be effective in pain control for up to 4-5 hours post-treatment.[rx]
  • The literature is still not conclusive on this topic and the results of one study may contradict or, on the contrary, reinforce the results of another study. Yet there is evidence supporting the beneficial effects of electrical stimulation, especially in combination with physiotherapy exercises.

Supervised Active Rehabilitation Program Used In Study

ISOMETRIC EXERCISE

  • Wrist flexors and extensors

ACTIVE RANGE OF MOTION EXERCISE

  • Assisted stretch to forearm flexors and extensor musculature and radial/ulnar deviation
  • Weight-bearing wrist extension exercise(hand on the table with the patient leaning forward on them) to patient tolerance
  • Active stretch to shoulder girdle and rotator cuff musculature
  • Active stretch to elbow flexor and extensor musculature

INTRINSIC HAND MUSCLE EXERCISE

  • Thumb/digit opposition
  • Repetitive squeezing of therapy
  • repetitive towel wringing exercise

STRENGTHENING ROUTINE

  • Biceps curl with 1,5-2 pound weights bilaterally
  • Shoulder abduction, flexion and extension reps with 2-pound weights bilaterally
  • Repetitive squeezing of a rubber ball in affected wrist
  • Flexion and extension of wrist using 1,5-pound weights increasing as tolerated

FUNCTIONAL ACTIVITIES

  • The patient is encouraged to resume pre-accident activities that involve the affected extremity (eg. writing, typing, cooking, etc.)

Complications Of Chauffeur’s Fracture

There were no major complications such as neurovascular injury, infection, or impaired wound healing. Surgery-related complication at 2-year follow-up included nonunion in 3 patients (11%),

  • DRUJ subluxation in 3 patients (11%),
  • Implant migration in 4 patients (14%),
  • Radiographic resorption of the ulnar styloid in 4 patients (14%).
  • Radiographic nonunion was noted in 1 patient in group A (8%) and 2 in group B (13%). Residual DRUJ subluxation was noted in 3 patients; all were in group B (20%).
  • Partial or complete radiographic resorption of the ulna was found in 1 patient in group A (8%) and 3 in group B (20%).
  • Implant migration was noted in 1 patient in group A (8%), and 2 in group B (13%).
  • Subsequent removal surgery due to implant irritation occurred in 13 patients (46%), with 4 in group A (31%) and 8 in group B (53%).
  • A total of 11 patients (39%) with surgery-related complications included 5 (38%) in group A and 12 (80%) in group B, with a significant difference

There are risks associated with any type of surgery. These include

  • Nonunion (1-5%)
  • Infection (~4.8%)
  • 4% in the surgical group develop adhesive capsulitis requiring surgical intervention
  • Bleeding
  • Problems with wound healing
  • Blood clots
  • Damage to blood vessels or nerves
  • Reaction to anesthesia
  • Hardware prominence
  • Malunion with cosmetic deformity
  • Restriction of ROM
  • The difficulty with bone healing
  • Hardware irritation
  • Fracture comminution (Z deformity)
  • Fracture displacement
  • Increased fatigue with overhead activities
  • Dissatisfaction with appearance
  • The difficulty with shoulder straps, backpacks and the like
  • ~30% of patient request plate removal
  • Superior plates associated with increased irritation
  • Superior plates associated with increased risk of subclavian artery or vein penetration

References

What Is Chauffeur's Fracture?